Non-Smoker Baseline Questionnaire

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Form Approved
OMB No. 0920-xxxx
Exp. Date xx/xx/xxxx
CDC National Media Campaign Evaluation
- Non-Smoker Baseline Questionnaire -

Public reporting burden of this collection of information is estimated to average 25 minutes per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. An agency may not conduct or sponsor, and a person is not required to respond to a collection of information unless it displays a currently valid OMB control number. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden to CDC/ATSDR Reports Clearance Officer, 1600 Clifton Road NE, MS D-74, Atlanta, Georgia 30333; ATTN: PRA (0920-xxxx).

SUBJECTS FOR QUESTIONNAIRE

SECTION B:		TOBACCO USE QUESTIONS
SECTION C:		ATTITUDES AND BELIEFS
SECTION D:		SECONDHAND SMOKE
SECTION E:		MEDIA USE AND AWARENESS
SECTION F:		CLOSING QUESTIONS


 SECTION B: TOBACCO USE QUESTIONS
NOTE: A RESPONSE OPTION OF “REFUSE TO ANSWER” IS INCLUDED FOR ALL ITEMS.  

[ASK IF Screener A2 = 1]

B1. You mentioned previously that you have tried cigarette smoking.  About how many cigarettes have you smoked in your entire life? Your best guess is fine. 

	1	1 or more puffs, but never a whole cigarette
	2	1 cigarette
	3	2 to 5 cigarettes 
	4	6 to 15 cigarettes (about half a pack)
	5	16 to 25 cigarettes (about a pack)
	6	26 to 99 cigarettes (more than a pack but less than 5 packs)
	7	5 packs or more

B2.	How old were you when you smoked a whole cigarette for the first time? Your best guess is fine. 

|_|_| Years	[RANGE: 7-55]	

B3. About how long has it been since you last smoked cigarettes -- even a puff?  

|_|_| Hours		[RANGE: 0-23]
|_|    Days		[RANGE: 0-6]
|_|_| Weeks		[RANGE: 0-3]
|_|_| Months		[RANGE: 0-11]
|_|_| Years		[RANGE: 0-97]


[ASK ALL]

B4. For the next series of questions, please tell us if you would say definitely not, probably not, probably yes, or definitely yes.  
Rationale: susceptibility to cigarette smoking and intention. Source: MTS and NYTS. 
	
1			2			3			4			
Definitely not       Probably not                   Probably yes	 Definitely yes      

	[RANDOMIZE]
B4_1. Do you think you will try a cigarette soon?
B4_2. If you started smoking regularly, do you think you could stop smoking anytime you wanted?  
B4_3. Do you think you will smoke a cigarette anytime during the next year?

SECTION C: ATTITUDES AND BELIEFS 

Social Norms of Smoking and SHS

C1.  Do you believe cigarette smoking is related to:  
Rationale: Beliefs about cigarette smoking and harmful to health. Source: NHIS.
	
[RANDOMIZE ORDER]		1	2
					Yes	No

    1. Lung Cancer
    2. Cancer of the mouth or throat
    3. Heart Disease
    4. Diabetes
    5. Emphysema
    6. Stroke
    7. Hole in throat (stoma or tracheotomy)
    8. Buerger’s Disease
    9. Amputations (removal of limbs); 
    10. Asthma
    11. Gallstones

C2.How likely do you think a smoker is to develop a smoking-related disease as a result of smoking?
Rationale: beliefs about cigarette smoking and harm to health. Source:  FL Online Adult Longitudinal Media Survey. 

    1. Extremely Likely
    2. Very Likely
    3. Somewhat Likely
    4. Very Unlikely
    5. Extremely Unlikely


The next few questions ask your opinion about smoke from other people’s cigarettes.

C3. Do you think that breathing smoke from other people’s cigarettes or from other tobacco products is 	…?
Rationale: Key Outcome Indicator 2.03.5; NATS Q95

    1. Not at all harmful to one’s health
    2. Somewhat harmful to one’s health
    3. Very harmful to one’s health

C4. How likely do you think it is that regularly breathing secondhand smoke from cigarettes would cause 	children to have asthma or breathing problems? 
Rationale:  Increased belief that cigarette smoking and secondhand smoke are harmful to health. 

    1. Extremely Likely
    2. Very Likely
    3. Somewhat Likely
    4. Very Unlikely
    5. Extremely Unlikely

C5.  How likely would you be to ask a stranger not to smoke around you if you couldn’t move away from their smoke—…?
Rationale: Key Outcome Indicator 2.03.4. Source: NATS 94

    1. Extremely Likely
    2. Very Likely
    3. Somewhat Likely
    4. Very Unlikely
    5. Extremely Unlikely

C6.   Please tell us if you strongly agree, agree, disagree, or strongly disagree with the following 	statements.
Rationale: Key Outcome Indicator 2.03.4.
	1	2	3	4	
	Strongly			Strongly  
					      disagree	Disagree         Agree	agree
 
	C6_1. Cigarette smoking has no serious effects on non-smokers.
	C6_2. Parents who live with their children should not be allowed to smoke in their homes.
C6_3. Adults should not smoke around other people in their home. 
	C6_4. I protect all other household members from any harm related to smoking. 

C7. Thinking about all the health problems in your community, how important is addressing the problem of tobacco use?  Would you say it is…
Rationale: Key Outcome Indicator 2.03.4.

    1. Among the most important health problems
    2. Equally as important as other health problems
    3. Among the least important health problems
    4. Don’t know
	

C8.  In general, how do the adults you spend time with feel about cigarette smoking by adults?  Do they feel it is…
Rationale: Key Outcome Indicator 2.03.4.

    1. Totally acceptable
    2. Somewhat acceptable
    3. Neither acceptable nor unacceptable
    4. Somewhat unacceptable
    5. Totally unacceptable
	
C9. How do the adults you spend time with feel about someone smoking if children are present?  Do they feel it is…
Rationale: Key Outcome Indicator 2.03.4.

    1. Totally acceptable
    2. Somewhat acceptable
    3. Neither acceptable nor unacceptable
    4. Somewhat unacceptable
    5. Totally unacceptable


SECTION D: SECONDHAND SMOKE

D1. Other than yourself, does anyone who lives in your home smoke cigarettes now?
Rationale: Environment/Norms Source: NYATS

    1. Yes
    2. No

D2.  Not counting decks, porches, or garages, during the past 7 days, that is, since last [today’s day of week], on how many days did someone other than you smoke tobacco inside your home while you were at home?
Rationale: Key Outcome Indicator 2.04.4; NATS Q73

        	Number of days____________

D3. Not counting decks, porches, or garages, inside your home, is smoking …?
Rationale: Key Outcome Indicator 2.04.4; NATS Q74

    1. Always allowed
    2. Allowed only at some times or in some places
    3. Never allowed

D4. Not counting motorcycles, in the vehicles that you and your family members who live with you own or lease, is smoking …
Rationale: Key Outcome Indicator 2.04.4; NATS Q88

    1. Always  allowed in all vehicles
    2. Sometimes allowed in at least one vehicle
    3. Never allowed in any vehicle
    4. My family does not own or lease a vehicle

D5. During the past 3 months, have you talked to any family members or friends about the dangers of smoking?
    1. Yes
    2. No

D5a. During the past 3 months, did you encourage a friend or family member to quit smoking? Rationale: cessation. Source: adapted from TUS-CPS.
    1. Yes
    2. No

D6. Among close friends, do…

    1. All of them smoke?
    2. Most of them smoke?
    3. Most them NOT smoke?
    4. None of them smoke?

D7. Among close relatives, do…

    1. All of them smoke?
    2. Most of them smoke?
    3. Most them NOT smoke?
    4. None of them smoke?


D8. How many of your family members have quit smoking or are currently quitting smoking?

    1. None
    2. Only a few
    3. Some
    4. Most
    5. All
	
D9. How many of your friends have quit smoking or are currently quitting smoking?

    1. None
    2. Only a few
    3. Some
    4. Most
    5. All


SECTION E. MEDIA USE AND AWARENESS

E1. On an average day, how much television do you watch?
Rationale: use of television. Source: FL Online Adult Longitudinal Media Survey. 

    1. None
    2. Less than one hour
    3. About 1 hour
    4. About 2 hours
    5. About 3 hours
    6. About 4 hours
    7. 5 hours or more

E2. On an average day, how many hours do you listen to the radio?
Rationale: use of radio. Source: FL Online Adult Longitudinal Media Survey. 

    1. None
    2. Less than one hour
    3. About 1 hour
    4. About 2 hours
    5. About 3 hours
    6. About 4 hours
    7. 5 hours or more

E3. On an average day, how many hours do you use the Internet for personal reasons?
Rationale: use of internet. Source: FL Online Adult Longitudinal Media Survey. 

    1. None
    2. Less than one hour
    3. About 1 hour
    4. About 2 hours
    5. About 3 hours
    6. About 4 hours
    7. 5 hours or more

E4. What type of Internet connection do you have for your home computer or other primary computer?
Rationale: ability to view ads online. Source: NY Media Tracking Survey Online. 

    1. Cable/DSL/Broadband/High-Speed
    2. Dial-Up
    3. Not sure

E5. In the past 3 months, how often have you seen ads against smoking on television?
Rationale: exposure to tv ads. Source: MTS (replaced “anti-smoking” with “ads against smoking.”) 

    1. Never
    2. Rarely
    3. Sometimes
    4. Often
    5. Always

E6. In the past 3 months, how often have you heard ads against smoking on the radio?
Rationale: exposure to radio ads. Source: MTS (replaced “anti-smoking” with “ads against smoking.”) 

    1. Never
    2. Rarely
    3. Sometimes
    4. Often
    5. Always

E7. In the past 3 months, how often have you seen ads against smoking on in newspapers or magazines?
Rationale: exposure to tv ads. 

    1. Never
    2. Rarely
    3. Sometimes
    4. Often
    5. Always

E8. In the past 3 months, how often have you seen ads against smoking, videos, or websites online?
Rationale: exposure to web ads and/or online videos. Source: MTS (replaced “anti-smoking” with “ads against smoking.”) 

    1. Almost every time I was online
    2. Frequently when I was online
    3. Occasionally when I am online
    4. Never/Not that I remember
    5. I rarely or never go online or use the internet

E9. A telephone quitline is a free telephone-based service that connects people who smoke cigarettes with someone who can help them quit. Are you aware of any telephone quitline services that are available to help smokers?   
Rationale: Key Outcome Indicator 3.08.6; NATS Q44

 	1.	Yes
	2.	No

[IF E9=1, ASK E9a]

E9a. In the past 3 months, have you recommended any family members or friends that smoke to call a telephone quitline?

    1. Yes
    2. No
 
E10.  Have you heard of 1-800-QUIT-NOW?
Rationale: Awareness of quit line as smoking cessation resource

	1.	Yes
	2.	No

[IF E10=1, ASK E10a]

E10a. In the past 3 months, have you recommended any family members or friends that smoke to call 1-800-QUIT-NOW?
Rationale: Awareness of and communication about quit line as smoking cessation resource

    1. Yes
    2. No


E11.  Have you ever heard of any quit smoking websites online?
Rationale: awareness of internet smoking cessation resources. 

    1. Yes
    2. No

[IF E11 = 1, ASK E12]

E12.  Have you ever visited any quit smoking websites online?
Rationale: awareness of internet smoking cessation resources. 

    1. Yes
    2. No

[IF E12 = 1, ASK E13]

E13.  Have you visited any quit smoking websites online in the past 3 months?
Rationale: awareness of internet smoking cessation resources. 

    3. Yes
    4. No

E14.  Have you ever heard of the Website www.smokefree.gov?
Rationale: awareness of internet smoking cessation resources. 

    1. Yes
    2. No

[IF E14 = 1, ASK E15]

E15. Have you ever visited www.smokefree.gov?
Rationale: awareness of internet smoking cessation resources. 

    1. Yes
    2. No

[IF E15 = 1, ASK E16]

E16. Have you visited www.smokefree.gov in the past 3 months?
Rationale: awareness of internet smoking cessation resources. 

    1. Yes
    2. No

[IF E14=1, ASK E16a]

E16a. In the past 3 months, have you recommended any family members or friends that smoke to visit www.smokefree.gov?

    1. Yes
    2. No

E17. In the past 3 months, have you seen or heard advertisements for products to help people quit smoking, such as nicotine patches or gums?
Rationale: awareness of internet smoking cessation resources. 

    1. Never
    2. Rarely
    3. Sometimes
    4. Often
    5. Always


E18. Have you ever seen or heard of any ads on television or radio with the following themes or slogans? 
Rationale: Ad awareness. Source: Adapted from FL Online Adult Longitudinal Media Survey. 
	
[RANDOMIZE ORDER]		1	2
					Yes	No

E18_1. TIPS FROM A FORMER SMOKER
E18_2. TRUTH
E18_3. BECOME AN EX
E18_4. EVERY CIGARETTE IS DOING YOU DAMAGE
E18_5. TOBACCO FREE LIVING


SECTION F: CLOSING QUESTIONS

F1. How many children aged 17 or younger live in your household 6 months or more of the year?
Rationale: demographics. Source: US DHHS Standards. Dorsey and Graham. 2011. New HHS Data Standards for Race, Ethnicity, Sex, Primary Language, and Disability Status. JAMA 306(21):2378-2379.

__	Number of Children


F2. What is your sex? 
Rationale: demographics. Source: US DHHS Standards. Dorsey and Graham. 2011. New HHS Data Standards for Race, Ethnicity, Sex, Primary Language, and Disability Status. JAMA 306(21):2378-2379.

    1. Male
    2. Female


F3. Are you Hispanic, Latino/a, or of Spanish origin? (1 or more categories may be selected)
Rationale: demographics. Source: US DHHS Standards. Dorsey and Graham. 2011. New HHS Data Standards for Race, Ethnicity, Sex, Primary Language, and Disability Status. JAMA 306(21):2378-2379.

    1. No, not of Hispanic, Latino/a, or Spanish origin
    2. Yes, Mexican American, Chicano/a
    3. Yes, Puerto Rican
    4. Yes, Cuban
    5. Yes, Another Hispanic, Latino/a, or Spanish origin

F4. What is your race? (1 or more categories may be selected)
Rationale: demographics. Source: US DHHS Standards. Dorsey and Graham. 2011. New HHS Data Standards for Race, Ethnicity, Sex, Primary Language, and Disability Status. JAMA 306(21):2378-2379.


    1. White
    2. Black or African American
    3. American Indian or Alaska Native
    4. Asian Indian
    5. Chinese
    6. Filipino
    7. Japanese
    8. Korean
    9. Vietnamese
    10. Other Asian
    11. Native Hawaiian
    12. Guamanian or Chamorro
    13. Samoan
    14. Other Pacific Islander

F5. What is the highest grade or level of schooling you completed?
Rationale: demographics. Source: NATS .

    1. 5th grade or less
    2. 6th grade 
    3. 7th grade 
    4. 8th grade 
    5. 9th grade 
    6. 10th grade 
    7. 11th grade 
    8. 12th grade, no diploma 
    9. Ged or equivalent 
    10. High school diploma 
    11. Some college, no degree 
    12. Certificate, diploma, or associate degree: occupational, technical, or vocational program 
    13. Associate degree: academic program 
    14. Bachelor’s degree 
    15. Master’s degree 
    16. Professional school degree (examples: md, dds, dvm, llb, jd) 
    17. Doctoral degree (examples: phd, edd) 

The next question is about the total income of YOUR HOUSEHOLD for the PAST 12 MONTHS.  Please include your income PLUS the income of all members living in your household (including cohabiting partners and armed forces members living at home).  Please count income BEFORE TAXES and from all sources (such as wages, salaries, tips, net income from a business, interest, dividends, child support, alimony, and Social Security, public assistance, pensions, or retirement benefits).

F6. Thinking about members of your family living in this household, what is your combined
annual income, meaning the total pre-tax income from all sources earned in the past
year? 
Rationale: demographics. Source: HINTS. 

    1. $0 to $9,999
    2. $10,000 to $14,999
    3. $15,000 to $19,999
    4. $20,000 to $34,999
    5. $35,000 to $49,999
    6. $50,000 to $74,999
    7. $75,000 to $99,999
    8. $100,000 to $199,999
    9. $200,000 or more

F7. Are you now …?
Rationale: demographics. Source: NATS 
    1. Married
    2. Living with a partner
    3. Divorced
    4. Widowed
    5. Separated
    6. Single, that is, never married and not now living with a partner
96. Other (Specify)

F8. Which statement best describes your current employment status?
Rationale: demographics. Source: Knowledge Networks panel question.

    1. Working full time as a paid employee
    2. Working full time, self-employed
    3. Not working, on temporary layoff from a job
    4. Not working, looking for work
    5. Not working, retired
    6. Not working, disabled
    7. Not working, other

F9. How many smoking or tobacco related web surveys like this have you completed with Knowledge Networks during the past year?
Rationale: potential exposure to similar surveys. Source: Knowledge Networks panel question.
NOTE: This is a standard question that Knowledge Networks asks its panel members.  

    1. None
    2. 1 survey
    3. 2 surveys
    4. 3 surveys
    5. 4 surveys
    6. 5 or more surveys

[IF F9 > 2, ASK F10]

F10. Did you view or listen to any videos or other advertisements about quitting smoking in any of these surveys?
Rationale: potential exposure to similar ads/surveys. Source: Knowledge Networks panel question.
NOTE: This is a standard question that Knowledge Networks asks its panel members.  

    1. Yes
    2. No

F11. Do you currently participate in any other online web panels besides Knowledge Networks?
Rationale: potential exposure to similar surveys.. Source: Knowledge Networks panel question.
NOTE: This is a standard question that Knowledge Networks asks its panel members.  

    1. Yes
    2. No

F12. In what state do you currently reside?
Rationale: demographics. Source: Knowledge Networks panel questions.
NOTE: This is a standard question that Knowledge Networks asks its panel members.  


	_________Pull Down List of States 

F13. What county do you live in?
Rationale: demographics. Source: Knowledge Networks panel questions.
NOTE: This is a standard question that Knowledge Networks asks its panel members.  

	_________Pull Down List of Counties 


F14. In what postal zip code do you live? ____________
Rationale: demographics. 

F15. Have you been diagnosed by a physician or other qualified 
medical professional with any of the following medical conditions? 
Rationale: Possible influencers for smoking cessation. Source: Knowledge Networks standard questionnaire.
NOTE: This is a standard question that Knowledge Networks asks its panel members.  

		1	2
		Yes	No

F15_1. Acid reflux disease
F15_2. ADHD or ADD
F15_3. Anxiety disorder
F15_4. Asthma, chronic bronchitis, or COPD
F15_5. Cancer (any type except skin cancer)
F15_6. Chronic pain (such as low back pain, neck pain, or Fibromyalgia)
F15_7. Depression
F15_8. Diabetes
F15_9. Heart attack
F15_10. Heart disease
F15_11. High blood pressure
F15_12. High cholesterol
F15_13. HIV/AIDS
F15_14. Kidney disease
F15_15. Mental health condition
F15_16. Multiple sclerosis
F15_17. Osteoarthritis, joint pain or inflammation
F15_18. Osteoporosis or osteopenia
F15_19. Rheumatoid arthritis
F15_20. Seasonal allergies
F15_21. Skin cancer
F15_22. Sleep disorders such as sleep apnea or insomnia   
F15_23. Stroke
F15_24. Something else
F15_25. None of these [Single select]

Thank you for completing today’s survey. Your input will greatly help researchers assess the impact of television ads about quitting smoking. 

You will be awarded 5,000 KN points for completing this survey. A follow-up survey will be sent to you in about 3 to 4 months and you will be awarded 15,000 KN points for completing that survey.